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Ukulele Donation Tracking Form

Please fill out this form after you have donated a UKC ukulele.

Thank you for your support! We rely on this information to make sure we can continue our mission of sending ukes home with kids. The information provided in this form will never be sold or shared with a third party and will be utilized solely for program development, tracking, and evaluation purposes for The Ukulele Kids Club, Inc.  For any questions or comments please email outreach@theukc.org 
1.HOSPITAL/SITE NAME (Please write the full name, no acronyms)
2.DATE OF DONATION (MM/DD/YYY) (If you do not remember the specific date, please write in the month and year)
Date / Time
  • 1900
  • 1901
  • 1902
  • 1903
  • 1904
  • 1905
  • 1906
  • 1907
  • 1908
  • 1909
  • 1910
  • 1911
  • 1912
  • 1913
  • 1914
  • 1915
  • 1916
SuSunday
MoMonday
TuTuesday
WeWednesday
ThThursday
FrFriday
SaSaturday
3.AGE OF RECIPIENT
4.GENDER OF RECIPIENT
5.DIAGNOSIS, UNIT OR LOCATION OF SERVICES
The section below is optional. You do not have to upload a picture of every ukulele you donate, but we are happy to receive any you may have. If you need a copy of the consent form, please access it here.
6.Please share any quotes from the kids here:
7.Please share with us any pictures or videos with proper consent.
No file chosen
8.This media is cleared for public-use.
9.Upload your consent form.
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